Resection of superior sulcus tumors (posterior approach)

Tumors of the superior sulcus are an uncommon form of NSCLC and historically have been associated with high rates of incomplete resection, local recurrence, and death. Recent data from a multi-institutional study suggest that preoperative chemoradiation may improve the rates of complete resection and cure. Involvement of the vertebral body or brachial plexus, areas once considered unresectable, is amenable to advanced techniques of spinal reconstruction and may lead to long-term survival in selected patients.     

Hybrid video-assisted and limited open (VALO) resection of superior sulcus tumors

Purpose

To compare the postoperative recovery of patients with superior sulcus tumors (Pancoast tumors) following conventional open surgery vs. a hybrid video-assisted and limited open approach (VALO).

Methods

The subjects of this retrospective study were 20 patients we operated on to resect a Pancoast tumor. All patients received induction chemo-radiation followed by surgery, performed via either a conventional thoracotomy approach (n = 10) or the hybrid VALO approach (n = 10). In the hybrid VALO group, lobectomy and internal chest wall preparation were performed using a video technique, with rib resection and specimen removal through a limited incision.

Results

There was no mortality in either group. Two patients from the thoracotomy group required mechanical ventilation, but there was no major morbidity in the hybrid VALO group. The operative times were similar for the two procedures. The average length of hospital stay was shorter and the average pain scores were significantly lower in the hybrid VALO group. The incidence of chronic pain was 10 % in the hybrid VALO group vs. 50 % in the thoracotomy group.

Conclusions

Hybrid VALO resection of Pancoast tumors is feasible and safe, resulting in faster patient recovery and a significantly lower incidence of severe chronic pain than open thoracotomy. We conclude that centers experienced with video-assisted lobectomy should consider hybrid VALO surgery as the procedure of choice for Pancoast tumors.

     

Analysis of the surgical treatment for superior sulcus tumors

Purpose

This study was undertaken to assess the mortality, complication, and major morbidity rates of surgical treatment for superior sulcus tumors (SSTs), and to estimate the significance of prognostic factors.

Methods

We retrospectively reviewed the hospital records of 50 consecutive patients undergoing surgical treatment for SSTs between 1992 and 2007. The significance of risk factors for an adverse outcome was investigated.

Results

Both the thirty-day and in-hospital mortality rates were 0 %. Complications developed in 18.0 % (9/50) of the patients. The overall 5-year survival was 32.7 %. Pathological T4 and N1 or more were the risk factors predicting an adverse outcome. Survival was not significantly influenced by the preoperative symptoms, the histological type, the invaded organ or the curability.

Conclusion

Surgical treatment for SSTs is associated with acceptable overall morbidity and mortality rates. However, special care must be taken for the patients with pathological T4 and N1 or higher tumors. Preoperative chemoradiotherapy followed by surgical treatment has become a logical strategy for SSTs. Preoperative chemoradiotherapy for SSTs may yield better results than surgery alone.     

Transmanubrial transclavicular approach in tumors of the brachial plexus

The standard transclavicular approach allows only limited and narrow exposure if the cervical thoracic region for the resection of tumors of the brachial plexus is involved. We report 2 cases of retroclavicular tumors of the brachial plexus. We performed a complete resection in both cases using the transmanubrial transclavicular approach. This approach consists of retracting an osteomuscular flap that involves the medial portion of the clavicle, part of the sternal manubrium, the sternoclavicular joint, and the sternocleidomastoid muscle. We describe and discuss this approach, which provides access to the entire brachial plexus and the major vessels, thereby affording excellent control of the vessels; it is the approach of choice for tumors in this location.     

Anterior approach for tumor of the superior sulcus.

A new approach for the resection of tumors of the superior sulcus is described. The exposure is gained through a proximal median sternotomy extended into the anterior fourth intercostal space as well as to the base of the neck on the appropriate side. This approach guarantees excellent exposure of the tumor, subclavian artery, and brachial plexus as well as access to the ribs posteriorly and the border of the vertebral bodies. Hilar dissection is readily accomplished without change of the patient's position. Disadvantages relate to depth of exposure, especially in large individuals, and the complicated wound closure.     

Resection of superior sulcus carcinomas (anterior approach)

Physicians' understanding of the anatomy, biology [9], and treatment outcome [12] for superior sulcus carcinoma has changed greatly during the last decade [2,3]. One of the major advances in this regard has been the introduction of anterior approaches for resection. These approaches increase the likelihood of complete resection and permit resection of tumors that were previously considered technically unresectable. Each approach must be understood in detail to avoid incomplete operations and life-threatening complications. These technical advances, with recent evidence that preoperative chemoradiotherapy leads to higher complete resection rates, overall survival, and local control than do radiation and surgery alone [32], have changed physicians' attitudes toward superior sulcus carcinomas, especially for those tumors (eg, T4) previously considered technically unresectable and oncologically incurable. It is hoped that, in the future, resection of disease invasion of the brachial plexus above C7 will be technically feasible [33], and that new drugs will reduce the risk of systemic relapse after resection.     

Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor.

Transmanubrial osteomuscular sparing approach (TMA) has been recently proposed for the treatment of apical chest tumor to allow a safer subclavian artery control with a less invasive procedure for the patient. The present technique combines the antero-lateral muscle-sparing thoracotomy with TMA for lung cancer patients in whom extended resection of cervico-thoracic structures as well as anatomic lung resection and radical lymph nodes dissection are required.     

Management of superior sulcus tumors: experience with 139 cases treated by surgical resection

BACKGROUND: The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival. METHODS: Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV. RESULTS: The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival. CONCLUSIONS: The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.     

Videothoracoscopic resection of neurogenic tumors of the superior sulcus using the harmonic scalpel

Resection of neurogenic tumors located in the paravertebral sulcus carries a risk of injury to the adjacent nervous structures and also to critical intercostal arteries supplying the anterior spinal artery. To avoid such complications, we have used the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for the dissection of neurogenic tumors in 2 consecutive patients operated on by videothoracoscopy. The Harmonic Scalpel functions with ultrasonic energy, producing less heat than a regular electrocautery and allows a safer dissection of tumors located in the posterior mediastinum, particularly those located in the superior paravertebral sulcus.     

Robotic video-assisted thoracoscopy: minimally invasive approach for management of mediastinal tumors

In spite of difficult anatomic access for tumors of mediastinum, surgical resection remains the best diagnostic and therapeutic approach. Widespread acceptance of video-assisted thoracoscopy (VATS) is restricted by the limiting nature of instruments and suboptimal visualization. Robotic assisted minimally invasive surgery seems to hold most promise in remote, narrow anatomical regions. After obtaining approval from Institutional Review Board (IRB), a retrospective review of prospectively collected database on patients that underwent Robotic VATS between 2009 and 2013 was conducted. Forty-eight patients underwent RVATS resection of mediastinal tumor. One procedure (2.1%) was converted to open. The size of the mass ranged from 0.6 to 12.5 cm in greatest dimension (mean 5.16 cm). The mean duration of procedure was 127.96 min (60–240 min). Five patients (10.4%) had early postoperative complications including chylothorax (1 patient), new onset atrial fibrillation (1 patient), pleural effusion (1 patient), empyema (1 patient), and bleeding (1 patient). Mean follow-up time was 186 days (10–1300 days). Two patients (4%) with invasive thymoma developed local recurrence. The present study documents the feasibility of RVATS in the management of mediastinal tumors irrespective of the location in various mediastinal compartments. The role for careful and complete excision of the tumor, and surveillance afterward on invasive thymoma, was noted in our study, as in literature.